Functional Area: Responsibilities of Management (ROM)
Standard 1 | Indicator 2 | Category: YELLOW 🟡 (80% required)
The Moment the Assessor Stopped Writing and Started Watching
The PHC assessor had arrived at Dr. Rabia Saleem’s clinic in Sadiqabad at nine forty-five on a Wednesday morning. He introduced himself to the receptionist, showed his identification, and said he would begin the assessment outside before coming in. Standard procedure. He stood near the entrance with his clipboard and began working through the first few items on his form.
He was still outside when Naseem arrived.
Naseem was sixty-seven years old, a hypertension patient who had been coming to Dr. Rabia’s clinic for four years. She had suffered a mild stroke eight months ago and now uses a wheelchair. Her son Bilal pushed her to her appointments most mornings, a ten-minute walk from their house, a routine they had developed.
The clinic entrance had two concrete steps. There was no ramp.
Bilal was a strong young man and had managed the steps before. He tilted the wheelchair back, lifted the front wheels, bumped up the first step, repositioned, and lifted again for the second. Naseem gripped the armrests. It took about forty-five seconds and some visible effort.
The assessor watched the entire thing without writing a word.
When Dr. Rabia came out to greet him five minutes later, he was polite and professional, as he had been throughout. But when he reached Indicator 2 on his form, he asked her a question she had not expected: “Is this the only entrance to the clinic?”
It was.
“And there is no ramp?”
There was not.
He explained, as he wrote his score, that the indicator was specifically designed to capture this situation: a patient or attendant encountering a physical barrier before even entering the building. It was a YELLOW indicator. He would score it on the partial side.
Dr Rabia watched him note it down and felt something she would later describe as a specific type of embarrassment, not the embarrassment of being caught doing something wrong. Still, the embarrassment of realising you had never thought about something that should have been obvious.
Naseem had been managing those two steps for eight months. Nobody had thought to fix them.
What Indicator 2 Actually Requires
Indicator 2 is the second checkpoint under Standard 1, which requires your clinic to be identifiable and easily accessible. While Indicator 1 is about what people can read from the street, Indicator 2 is about what people can physically do when they get there.
The indicator reads: Patient/Client has easy access to the Clinic.
The word “easy” has a specific meaning in this context. The MSDS guidelines describe it in terms of the most vulnerable patients, people with disabilities, the elderly, those using wheelchairs, stretchers, walking frames, or crutches. If easy access for these patients is not in place, the indicator cannot be fully met.
The three specific requirements in the guidelines are:
1. Ramps where there are steps. If the entrance to your clinic is not on a level surface, meaning there are steps, an elevated threshold, or a raised platform, a ramp must be available for wheelchair and stretcher access. This applies to the entry, the exit, and, where applicable, the washroom.
2. Non-slippery surfaces. Any ramp or slope must have a surface that provides grip. This does not require expensive materials. The MSDS explicitly acknowledges that non-slip surfaces can be achieved simply by grinding and coarsening the existing surface. A textured finish on concrete, rubber matting, or anti-slip strips is an acceptable approach. The point is that a smooth concrete ramp on a rainy morning is a hazard in itself.
3. Wide enough doors. The entry, exit, and, where applicable, washroom doors must be wide enough to allow a wheelchair to pass through without difficulty. A standard adult wheelchair is approximately 60 to 65 centimetres wide and requires a door opening of at least 80 centimetres to pass through comfortably.
How the Assessor Scores This Indicator
This is a YELLOW indicator, which means the scoring is graduated and partial compliance is possible. Unlike Indicator 1, which produces a binary score based on the presence or absence of a PM&DC number, Indicator 2 allows a range.
Score of 10 (Fully Met): All three elements are in place. Entry and exit are accessible via ramp or are on a level surface. Ramps and slopes are non-slippery. Doors are wide enough for wheelchair passage. A patient using a wheelchair, walking frame, or stretcher can enter and exit without assistance or difficulty.
Score of 5 to 7 (Partially Met): Access exists but is not fully easy to use. For example, there is a ramp, but its smooth surface becomes slippery in wet weather. Or: the main door is wide enough, but the washroom door is too narrow. Or: the entry is accessible, but the exit is not. The assessor evaluates the overall accessibility situation and assigns a score that reflects how close to easy access the clinic actually is.
Score of 0 to 4 (Not Met): Access is genuinely difficult, and no facilitation is provided. Steps with no ramp. A narrow entrance with no alternative. A clinic setup that a patient in a wheelchair cannot navigate without being physically lifted or carried. This is not a theoretical failure; it is a daily experience for some patients at some clinics, and the MSDS treats it as a compliance failure.
Dr Rabia received a score of 5. The assessor’s reasoning: there was no ramp of any kind; the steps were only two in number; the entrance was otherwise wide; and the clinic’s interior layout was accessible. The situation was partially manageable but not easily accessible. Not for Naseem. Not without Bilal’s effort twice a day.
Why This Indicator Exists — and Who It Is Really For
Pakistan’s clinic environment varies enormously. Some clinics occupy purpose-built spaces with level entrances. Many are in converted shops, ground-floor residential units, or commercial plazas where the entrance involves one or more steps and where the design was never intended for medical use.
The patients who suffer most from this design are not difficult to identify. They are the elderly diabetic who has begun walking with a cane, the young mother with a newborn in a pram and a toddler in a stroller. The accident patient was brought in on a stretcher—the stroke survivor, like Naseem, who used to walk in alone and now cannot.
For years, the physical inaccessibility of small clinics was treated as an unfortunate fact of Pakistan’s urban environment rather than a correctable problem. The MSDS takes a different position: it treats accessibility as a baseline requirement, and it scores it. Not perfectly: a YELLOW indicator at 80% is not the same as a national infrastructure mandate, but it raises the question in every assessment and forces every clinic owner to answer it.
The answer does not have to be expensive. That is the part clinic owners often miss when they first read this indicator.
The Fix — And Why It Is Cheaper Than You Think
The most common barrier to fixing access issues is the assumption that compliance requires a contractor, planning permission, and significant construction cost.
It usually does not.
For the two-step entrance at Dr. Rabia’s clinic, a fabricator built a portable steel ramp in three days. It sits alongside the steps when not in use and slides into position for patients who need it. The surface was fitted with rubber anti-slip strips. It folds for storage.
That is the entire solution—one ramp. A score of 5 became a score of 9 at the reassessment.
For clinics where the entrance is on a level surface but the door is narrow, the fix depends on the lease and the structure. In some cases, a door frame can be widened. In others, particularly where the building is rented, and structural changes are not possible, the assessor will consider the context and score accordingly. The MSDS is not unmindful of the realities of small, rented clinical spaces.
What it does not accept is indifference. The question this indicator asks is simple: Have you thought about whether your patients can get in? The clinic owners who fail it are rarely those who tried and could not. They are mostly those who, like Dr Rabia before that Wednesday morning, had not thought about it.
You can also connect with the writer of this blog post series to share or receive suggestions: Dr. Junaid Rashid (Founder of UPMED) at 03042397393 (WhatsApp).
List of all the posts in this journey.